I AM A psychiatrist, a medical doctor who specialises in the treatment of mental illness.
Psychiatry is different to other branches of medicine. Psychiatric diagnoses are based on symptoms and stories rather than tests and scans. Each person comes with a unique set of troubles and strengths, problems and solutions. Everyone is different.
This is why I love psychiatry: nothing is stable, everything changes, and each person is unique. The suffering is real, but so is recovery after a time of crisis. I am in constant awe of the body’s ability to heal and the mind’s capacity to grow.
It helps that psychiatric treatments work for most people most of the time, even for severe conditions such as depression, bipolar disorder (manic depression), and schizophrenia. Numerous research studies show that cognitive-behavioural therapy (CBT) and antidepressant medications not only alleviate depression but also reduce relapse. Mindfulness-based therapies are also effective, making the range of options very broad. Even psychedelics might have a role.
Some treatments deliver benefits beyond what I might expect. Antipsychotic medication reduces symptoms of severe mental illness but is also associated with lower risk of early death in schizophrenia. Combined with psychological interventions and social support, treatment can make an enormous difference.
Psychological and psychiatric treatments are not perfect. Side-effects can occur. Sometimes, it takes time to identify a therapy that helps. But there are a growing number of psychological approaches and new medications that act in different, better ways, to suit a broader range of people. One size does not fit all.
I qualified as a doctor in Galway in 1996 and have worked in the Irish mental health service for almost a quarter of a century. At this stage, I must have seen tens of thousands of people with depression, anxiety, bipolar disorder, schizophrenia and a range of other conditions.
Community solutions
I have also seen many people with unhappiness or problems of living, rather than mental illness. These issues require family support, the help of friends, and strong community networks. Psychiatric services are at their best when we focus on mental illness, rather than the emotional ups and downs of everyday life. It is harmful to medicalise unhappiness.
We suffer, heal, and help each other in families, communities, and societies. We need community solutions for problems of living, accessible psychological care for mild psychological problems, and specialist inpatient and outpatient services for serious mental illness.
Mental health services have changed dramatically over recent decades. In the 1960s, Ireland had over 20,000 people in psychiatric hospitals, the highest rate in the world. By 2020, we had 1,826 adult psychiatry inpatients, and 50 under the age of 18 – a dramatic reduction.
We have the third lowest number of psychiatry inpatient beds per 100,000 population in the EU. Our involuntary admission rate (“sectioning”) is half that of England.
This shift to community care is very positive, but low admission rates come at a price – people with mental illness in prison, homeless, or at home, too ill to accept treatment, but not ill enough for treatment without consent under mental health legislation.
We need more inpatient beds, but nobody wants to return to the days of “mental hospitals”. Community services need a substantial boost, especially for children and adolescents.
Budget problems
Ireland devotes just 5.1% of our health budget to mental health. Sláintecare recommends 10 per cent. The World Health Organisation suggests 12%. In the UK, it is almost 13%.
This low budget has knock-on effects. Recruitment problems are endemic in psychiatry. Consultant posts commonly attract zero applicants. Better resourcing would help with recruitment, morale, and staff retention. Like all health professionals, doctors enter medicine to help people, but need supports and a robust framework to do so.
Positive change is possible. Between 1990 and 2016, the global rate of suicide fell by a third. While there is still much more progress to be made, and even one suicide is one too many, this is an enormous change by any standards. Even in the midst of the Covid-19 pandemic, suicide in the US fell by almost 6% in 2020. Even at the worst of times, some things can get better.
Used correctly, psychological and psychiatric treatments work for most people most of the time, but they are not perfect and are not enough on their own. Psychological engagement and social support are vital. A balance is needed, delivered with humility, holism, and hope.
We need more services to make this happen. Social and political activism is essential, to achieve better funding for psychiatric services, more housing for people with mental illness, a meaningful safety net for those who fall between the cracks, and reform of criminal law, court procedures, and prison policies to better protect the rights of people with mental illness.
These issues extend well beyond the health service. Every family in Ireland is touched in some way by psychological problems, mental illness, or suicide.
When it comes to mental health, there is no “them”; there is only “us”. We need to fix this – and we can.
Brendan Kelly is Professor of Psychiatry at Trinity College Dublin and author of In Search of Madness: A Psychiatrist’s Travels Through the History of Mental Illness (Gill Books).
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